First Middle & Last Name*:  

Address*:  

Telephone Number*:  

Employer Name & Address*:  

Are you in the military?*:  

Dates during which you've been domiciled in Colorado*:  

Spouse's First Middle & Last Name*:  

Spouse's Address*:  

Spouse's Telephone Number*:  

Spouse's Employer's Name & Address*:  

Is your spouse in the military?*:  

Dates during which spouse has been domiciled in Colorado*:  

Date & place of marriage*:  

Date of physical separation (if applicable)*:  

Is the wife pregnant?*:  

Full Name & Birthdate of Children*:  

Have you participated in any proceedings regarding the children concerning parental responsibilities, decision-making or parenting time?*:  

If so, indentify the court, case number, state, date & type of proceeding*:  

Do you know of any proceedings that could affect your case such as domestic violence, enforcement of Court orders, restraining orders, parental rights termination or adoptions?*:  

If so, identify the court, case number, state, date, and type of proceeding*:  

Does anyone else have physical custody of the children or claim parental responsibility rights, custody or visitation/parenting time?*:  

If so, identify their names and addresses*:  

Identify the name, address and relationship of each person that you child has lived with over the past 5 years*:  

Have the parents or children received benefits or public assistance from the state DHS or County Social Services?*:  

If so, idenfity the person(s) receiving benefits, the County & State and Case Number*:  

Have any temporary or permanent protection/restraining orders been issued against either party within 2 years?*:  

Have you reached an agreement about the children or child support?*:  

If so, state the agreement*:  

Confidential Email Address*: